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Allergies

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NO

Select that applies

Antihistamines
Cephalexin
Codein
Decongestants
Dilantin
Hormones
Iodine
Mophene
Penicillin
Phenobarbital
Sulpha
Tetanus
Tetracycline
No known Allergies

What Are your current medications on Allergies?

Has any relative been diagnosed with any of the following conditions? Select that applies

Alzheimer'sDisease
Anxiety Sate
Arthritis
Cancer
Cardiac Bypass
Chronic Fatigue Syndrome
Depression
Diabetes
Divertculities
Drug or Alcohol Addiction
Drug Allergy
Emphysema
Epilepsy
Heart Disease
Hemochromatosis
High Blood Pressure
Parkinson's Disease
Prostatic Diease
Stroke
Thyroid Disease
Tuberculosis

If you checked any of the following above please elaborate

Please Fill your Family History (Mother/Father/Sibling) (Alive/Deceased) and the cause of Death if applicable

Mother- Alive, Father-Deceased, Cause - Stroke, Sibling-Alive

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